Menstrual Cycle: The Importance of Both the Phases and the Transitions Between Phases on Training and Performance

Abstract

The authors present opinions based on their applied experiences of working with female athletes in combination with the existing evidence-based literature. Most of the existing menstrual cycle research focuses on a few steady-state time points within the pre-defined menstrual cycle phases, yet this disregards the day-to-day hormonal changes that women have to accommodate to perform optimally and consistently. The traditional research models are inadequate for studying symptoms and symptom management, and ultimately for supporting athletes to perform well throughout the entirety of their cycle. As such, the monitoring of the day-to-day variation, particularly during the transitions between menstrual cycle phases appears to be an important “overlooked” consideration. This is particularly pertinent considering the known intra-individual and inter-individual variation in menstrual cycle characteristics. Anecdotal and research evidence supports the idea that athletes can use non-pharmacological solutions to mitigate negative menstrual cycle symptoms and do not need to “grit their teeth and roll with it”. However, further research (including case studies) is needed in this important research area. Such knowledge should be and needs to be widespread amongst practitioners and athletes as they should not have to figure this out alone. As such, researchers and practitioners need to put more work into understanding symptom aetiology, symptom clusters and their relationship with hormonal changes, menstrual cycle phases and transitions, with potential for a profound impact on individual athlete health and well-being. In so doing, those working with female athletes need to continue building on the recent progress made in educating athletes and practitioners; for example, normalising the discussion of and about the menstrual cycle and all of its implications.

Full text

Vol.:(0123456789)
Sports Medicine (2022) 52:1457–1460
https://doi.org/10.1007/s40279-022-01691-2
CURRENT OPINION
Menstrual Cycle: The Importance ofBoth thePhases
andtheTransitions Between Phases onTraining andPerformance
GeorgieBruinvels1,2,3 · AnthonyC.Hackney4· CharlesR.Pedlar1,2,3
Accepted: 3 April 2022 / Published online: 29 April 2022
© Crown 2022
Abstract
The authors present opinions based on their applied experiences of working with female athletes in combination with the
existing evidence-based literature. Most of the existing menstrual cycle research focuses on a few steady-state time points
within the pre-defined menstrual cycle phases, yet this disregards the day-to-day hormonal changes that women have to
accommodate to perform optimally and consistently. The traditional research models are inadequate for studying symptoms
and symptom management, and ultimately for supporting athletes to perform well throughout the entirety of their cycle. As
such, the monitoring of the day-to-day variation, particularly during the transitions between menstrual cycle phases appears
to be an important “overlooked” consideration. This is particularly pertinent considering the known intra-individual and
inter-individual variation in menstrual cycle characteristics. Anecdotal and research evidence supports the idea that athletes
can use non-pharmacological solutions to mitigate negative menstrual cycle symptoms and do not need to “grit their teeth
and roll with it”. However, further research (including case studies) is needed in this important research area. Such knowledge
should be and needs to be widespread amongst practitioners and athletes as they should not have to figure this out alone.
As such, researchers and practitioners need to put more work into understanding symptom aetiology, symptom clusters
and their relationship with hormonal changes, menstrual cycle phases and transitions, with potential for a profound impact
on individual athlete health and well-being. In so doing, those working with female athletes need to continue building on
the recent progress made in educating athletes and practitioners; for example, normalising the discussion of and about the
menstrual cycle and all of its implications.
1 Background
Female sex hormone levels in eumenorrheic women can
change by over 100% in a 24-h window of time [1]. While
the physiological and psychological implications of such
dramatic changes are incompletely understood, our first-
hand experience with athletes over many years tells us that
it is these sharp alterations in sex hormone levels that can
be associated with adverse, often detrimental, symptoms.
Common symptoms such as severe cramps, vomiting and
injury flare-ups can all be debilitating and wholly incompat-
ible with peak performance. Therefore, it is critical that the
significance of these occurrences in the sport setting not be
overlooked if practitioners are to provide helpful support to
female athletes.
Our intention in this commentary is to assert that there is
a clear case for practitioners and researchers to: (1) recognise
the impact that menstrual cycle (MC) symptoms can have
on aspects of performance and overall wellness (e.g. sleep
patterns, recovery time and mood) throughout the entirety of
the MC and (2) to not have an over-simplifying perspective
on the MC phases (i.e. just mid-follicular vs mid-luteal), and
in turn raise awareness of the importance of the day-to-day
variation including transition periods between MC phases
on athletes training and performance.
* Georgie Bruinvels
georgie.bruinvels.14@ucl.ac.uk
1 St Mary’s University, Twickenham, London, UK
2 Orreco Ltd, Business Innovation Unit, NUI Galway, Galway,
Ireland
3 Institute ofSport, Exercise andHealth, UCL, 170 Tottenham
Court Road, LondonW1T7HA, UK
4 University ofNorth Carolina, ChapelHill, NC, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1458 G.Bruinvels et al.
2 MC Model
In the literature, the MC has frequently been split into
physiological phases from the most simplistic (two phases)
to the highly detailed (seven phases) [6]. However, most
of the prior research informing our practices with athletes
tends to rely on a three-phased model with the assump-
tion of steady-state hormone levels existing; menstruation
(low sex hormones, early follicular), pre-ovulation (high
oestrogen, late follicular) and luteal (high oestrogen and
progesterone). Yet this three-phased model disregards the
hormonal changes punctuating the transitions from oes-
trogen dominance (late follicular phase) to ovulation, then
to a greater hormone level phase where both oestrogen
and progesterone are prominent (luteal phase), and finally
returning to menstruation. The translational utility of these
mid-phase studies for athletic use is weak. The hormonal
changes during phase transition can be rapid and large
in magnitude creating a dramatic change in the hormo-
nal milieu of a woman and challenging the maintenance
of homeostasis [1]. Crucially, the pre-menstrual phase,
typically bracketed into the luteal phase, is a key win-
dow of significant hormonal decline and has been almost
exclusively ignored in its own right within sports science
research. Yet, it is in this pre-menstruation phase and dur-
ing the subsequent early follicular phase (menstruation)
where we have observed adverse MC symptoms in ath-
letes to be most prevalent, and where there is an increased
likelihood of a need for extended exercise recovery [7],
compromises to training and performance [8]. This pre-
menstruation window seems little studied or understood by
sports science researchers, thus there is minimal guidance
for practitioners. Similarly, the post-ovulatory increase in
progesterone can also challenge systemic physiology. Pro-
gesterone has numerous systemic actions on other tissues,
including affecting neuromodulation, metabolism and
thermoregulation and increasing basal body temperature
as well as having antiestrogenic actions [9–11]. Athletes
need to be able to perform consistently throughout their
MC, thus sports scientists must not be remiss and apply a
reductionist approach to research to support both practi-
tioners and athletes in maintaining consistent performance
throughout the entire hormonal cycle.
3 Symptom Burden
Besides anecdotal reports from athletes, evidence-based
findings support a physiological basis for MC symptoms.
One primary mechanism involves the pre-menstrual
progesterone withdrawal and associated acute-phase
inflammatory response [2]. This, when occurring in par-
allel with an intense training load (or other causes of
stress both psychological and physical) has the potential
to create the ‘perfect storm’ of excess fatigue and under-
performance in athletes, if not managed proactively [3].
That said, not all women and their cycles are alike, and it
is important to appreciate the significant inter-individual
and sometimes intra-individual variation in cycle length,
bleeding pattern, symptom type, severity and timing [4, 5].
The magnitude of symptoms, i.e. the number, frequency
and severity; and the common clusters of symptoms have
yet to be fully documented, but anecdotally, athletes can
report feeling great one day, and compromised by symp-
toms just 1day later. In our experience, it is rare to find
female athletes with no negative symptoms whatsoever
across their MC, but we recognise this is not a universal
occurrence. Despite this, empirical evidence evaluating
objective measures of performance (not symptoms) from
cohort studies at fixed, steady-state MC time points are
inconclusive with regard to whether there are performance
impacts [6]. This ambiguity in the existing evidence is a
call for more research.
4 Global Consideration forExercising
Women
When considered en masse, over 90% of eumenorrheic
(regularly menstruating) exercising women experience MC-
related symptoms (e.g. changes in mood, menstrual cramps,
fatigue, lower back pain), with 80% reporting symptoms or
interrelated performance decrements every cycle [5, 8].
Symptoms appear to be as common in the general popula-
tion and in elite athletes, and specific to the latter, recent
findings suggest 50–67% of elite athletes perceive their
exercise performance to be disrupted by their MC [8, 12,
13]. Furthermore, beyond the elite arena, given that adverse
symptoms are a known barrier to habitual exercise, better
understanding these symptoms, and subsequently finding
suitable ways of mitigating them, could positively impact
the lives of millions of women worldwide. The current situ-
ation is a wonderful opportunity for translational research.
Historically, a lack of education, knowledge and willingness
to discuss this topic has been a substantial limiting factor,
but fortunately, this is rapidly changing.
5 What Needs tobe Done? Actions!
The first priority is to continue to educate both athletes and
practitioners to normalise the conversation around the MC
and raise awareness that symptoms (negative or positive) are
common and are related to the natural physiological rhythms
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1459
Appreciating the Entirety of the Menstrual Cycle in Female Athletes
(i.e. hormonal changes) of the cycle. In addition to this, we
advocate cycle tracking, and symptom logging to understand
each individual’s profile (and to be able to detect deviations).
Cycle tracking can take a number of different forms, includ-
ing a simple paper diary or alternatively, there are several
mobile applications with cycle tracking features. In full dis-
closure, two authors (GB, CP) of this article must acknowl-
edge their involvement in the creation of the FitrWoman
mobile application, and that while this is a tool that can be
used in this instance, there are several other options.
Importantly, in our experience, negative symptoms can
often be mitigated with appropriate multi-disciplinary non-
pharmacological interventions and via trial and error (see
following), helping athletes to avoid routine use of over-
the-counter analgesics and anti-inflammatory drugs (e.g.,
non-steroidal anti-inflammatory drugs) or hormonal contra-
ception as a primary treatment option, which can each pre-
sent alternative concerns. Additionally, where resources are
available, measuring hormones regularly could be informa-
tive, helping to specifically identify MC phases, and the
magnitude or absence of hormone fluctuations (note: hor-
mone receptors are also expressed differently over a MC
[14], which may limit the insights that can be gained from
just measuring circulating hormones alone [15]). Ultimately
of course, as practitioners we need to be treating and manag-
ing the symptoms, not just the hormone levels. We propose
that the key element here is how an individual responds to
the changing ratio of reproductive hormones that present
dynamically throughout the cycle; therefore, monitoring
the dates of the cycle transients together with symptoms
can provide vital practical information and preclude the
essentiality, inconvenience and expense of regular hormone
profiling, which most likely is not available to the non-elite
female exerciser, and seldom available to the elite athlete.
Furthermore, the language used when educating and discuss-
ing the MC should be carefully considered. The societal con-
structs associated with negative unwanted symptoms before
and during menstruation need to be reframed to avoid artifi-
cially creating or reinforcing a barrier. Put simply, education
should be used to enable and empower, not limit.
Like many strategies adopted by athletes, there might not
be randomised controlled research trials providing evidence
to support every intervention strategy in every scenario, and
there probably never will be. However, there is evidence
that supports nutritional interventions (e.g. curcumin and
omega-3 intake) [16, 17] and exercise modes [18]. Further,
use of particular nutritional interventions and extending
sleep can reduce inflammation, which appears to be a key
factor in negative symptom development [19–23]. Unfortu-
nately, as far as we know, all such studies thus far demon-
strating anti-inflammatory effects of nutritional interventions
have been conducted exclusively in men. Nonetheless, we
have observationally noted that these strategies can have a
profound impact on women too. The advantage of nutrition
and sleep interventions is that they do no harm, in contrast
to the potential risks associated with long-term use of non-
steroidal anti-inflammatory drugs or counteractive hormo-
nal contraceptive use. Despite what is proposed herein, we
acknowledge our current insights are based upon a paltry
amount of evidence, further high-quality research is needed
to provide data-driven insights into symptoms (frequency
and severity), cycle length changes and symptom clusters as
well as testing non-pharmacological, MC phase-appropriate,
symptom mitigation strategies throughout the entirety of the
MC.
6 Conclusions
In female athletes, there is the potential and thus an overt
need to perform on any day of the MC, consequently the
impact of the day-to-day fluctuations in MC hormones and
symptoms needs to be better understood (i.e. studied, moni-
tored). Such monitoring in turn should be accompanied by
education and, where possible and needed, individualised
proactive management. Finally, the apparent disconnect
between much of the existing research and applied practice
needs to be addressed and rectified if we are to optimise the
potential of female athletes.
Declarations
Funding No funding has been received in relation to this work.
Conflicts of Interest/Competing Interests Georgie Bruinvels and
Charles R. Pedlar are employees or consultants with Orreco Ltd., crea-
tors of the free FitrWoman app.
Ethics Approval Not applicable.
Consent to Participate Not applicable.
Consent for Publication Not applicable.
Availability of Data and Material Not applicable.
Code Availability Not applicable.
Authors’ Contributions All authors contributed equally to writing this
Current Opinion.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
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